Acceptability of Computerized Cognitive Behavioral Therapy for Adults: Umbrella Review

Back on track - digital health applications to treat back pain of rheumatic patients? Results of a qualitative interview study

Non-specific low back pain (NLBP) is prevalent among patients with rheumatic conditions. Digital health applications (DiGAs) provide reimbursed, personalized home treatment for patients, promising to overcome limitations of traditional healthcare systems. However, the adoption and effectiveness of back pain-specific DiGAs in rheumatology are not well understood. This study aims to explore the experiences and perspectives of a diverse group of rheumatology stakeholders regarding the use of DiGAs for back pain management. Qualitative interviews and a focus group discussion were conducted with a wide range of stakeholders including rheumatic patients, rheumatologists, nurses and DiGA producers. The data were analysed using qualitative content analysis. The study included 15 interviews (10 rheumatic patients, 4 rheumatologists, 1 DiGA producer) and 1 focus group with mixed participants (n = 12). Most stakeholders valued the instant access to personalized and effective back pain treatment provided by DiGAs. Patients appreciated the flexibility and ease of use of DiGAs which can be used anywhere and anytime. Concerns were raised about insufficient guidance regarding correct execution of exercises, which was seen as potentially dangerous and unsettling for patients. Healthcare professionals (HCPs) highlighted barriers, such as the lack of reimbursement, time constraints, and inadequate DiGA-specific education as barriers to prescribing DiGAs. Additionally, poor patient onboarding often led to delays, increased skepticism, and premature discontinuation of therapy. Stakeholders emphasized the challenges of current care driven by a shortage of HCPs and generally supported usage of back pain DiGAs. Various barriers and solution approaches were identified to enhance the performance, usability, and implementation of DiGAs in rheumatology.

Enhancing quality of life in epilepsy with a digital intervention (emyna): Results of the ELAINE randomized controlled trial

OBJECTIVE

Despite the availability of pharmacological treatment for seizures, people with epilepsy (PwE) commonly experience impairments in quality of life (QoL). Given the limited access to psychosocial treatments for PwE, digital interventions could bridge treatment gaps and help improve QoL. The objective of this study was to examine the effectiveness of emyna, a fully automated digital intervention based on cognitive behavioral therapy (CBT) techniques, in improving health-related QoL among PwE who reported impairments in QoL. A previous trial showed that emyna was effective in improving depressive symptoms among PwE with a comorbid depressive disorder, but its effects on QoL among PwE without comorbid depression remain unknown.

METHODS

A pragmatic randomized controlled trial was conducted with N = 438 PwE (mean age = 37.5, 70.3% women, physician-verified diagnoses) who were assigned to the intervention group (n = 216), which used emyna alongside treatment as usual (TAU), or the control group (n = 222), which received TAU only. QoL and secondary outcomes such as general self-efficacy, medication adherence, general distress, and epilepsy-related work and social adjustment were assessed at baseline, 3 months, and 6 months. The primary outcome was QoL assessed with the Quality of Life in Epilepsy [QOLIE-31] total score at 3 months post-randomization.

RESULTS

Findings from the intent-to-treat analyses showed that after 3 months, participants in the intervention group experienced significant and clinically relevant improvements in health-related QoL compared to the control group (baseline-adjusted group difference = 4.5; 95% CI = [2.0, 6.9], p < 0.001; Cohen's d = 0.32). Effects on secondary outcomes did not reach statistical significance.

SIGNIFICANCE

This study extends previous research by demonstrating that emyna facilitates improvements in QoL in a diverse group of PwE treated in routine care settings. This CBT-based digital intervention therefore presents a convenient and cost-effective addition to healthcare providers' treatment repertoire.

PLAIN LANGUAGE SUMMARY

In our study, we tested a digital program called emyna, which conveys cognitive behavioral therapy (CBT) techniques to help improve the quality of life for people living with epilepsy. We found that those who used emyna alongside their usual treatments felt better about their quality of life compared to those who did not use the program. Emyna offers a new, convenient way for people with epilepsy to manage their condition, which can be used alongside currently available treatments.

Acceptability of Tele-mental Health Services Among Users: A Systematic Review and Meta-analysis

BACKGROUND

Mental disorders are currently a global public health concern, particularly after the coronavirus disease 2019 (COVID-19) pandemic. Mental health services gradually transitioned to teleservices, employing various methods like texting and videoconferencing. This meta-analysis aimed mainly to quantify the acceptability of tele-mental health services among both beneficiaries and providers. Secondary objectives included quantifying the usability of and satisfaction with these services.

METHODS

We conducted a systematic search of the following databases PubMed Central, SAGE, Google Scholar, Scopus, Web of Science, PubMed Medline, and EBSCO according to Preferred Reporting Items of the Systematic Reviews and Meta-Analysis (PRISMA) guidelines until December 2022.

RESULTS

Out of 3366 search results, 39 studies fully met the inclusion criteria. The pooled acceptability of tele-mental health services among beneficiaries was [71.0% with a 95% confidence interval (CI) of 63.0 - 78.5%, I2 = 98%]. Using meta-regression, four key factors contributed to this heterogeneity (R2 = 99.75%), namely, year of publication, type of mental disorder, participant category, and the quality of included studies. While acceptability among providers was [66.0% (95%CI, 52.0 - 78.0%), I2 = 95%]. The pooled usability of tele-mental health services among participants was [66.0% (95%CI, 50.0 - 80.0%), I2 = 83%]. Subgroup analysis revealed statistically significant results (p = 0.003), indicating that usability was higher among beneficiaries compared to providers.

CONCLUSIONS

The study highlighted a high acceptability of tele-mental health services. These findings suggest a promising outlook for the integration and adoption of tele-mental health services and emphasize the importance of considering user perspectives and addressing provider-specific challenges to enhance overall service delivery and effectiveness.

Cognitive Behavioral Therapy and Mindfulness-Based Cognitive Therapy for Depressive Disorders: Enhancing Access and Tailoring Interventions in Diverse Settings

Depressive disorders are an enormous societal burden given their high prevalence and impact on all facets of being human (e.g., relationships, emotions, motivation). There is a variety of evidence-based psychological treatments, with cognitive behavioral therapy (CBT) being the gold standard for major depression. Research has shown that mindfulness-based interventions (MBIs) such as mindfulness-based cognitive therapy (MBCT) are an effective relapse prevention and treatment for depression and that MBIs can be integrated in individual therapy. Furthermore, various delivery modes (e.g., digital-delivered therapy) and settings are offered to best meet different needs and improve accessibility: Evidence suggests that therapist-guided digital CBT, blended therapy, and, to some degree, digitalized MBIs may be an efficacious supplement to traditional face-to-face therapy. This chapter provides an overview of the principles and evidence base for CBT and MBCT as well as different delivery modes for depressive disorders in adults. Finally, chances and challenges of integration are discussed as implications for practice, as well as recommendations and ideas for future research.

Internet-delivered therapist-assisted cognitive behavioral therapy for gambling disorder: a randomized controlled trial

Objectives

Cognitive behavioral therapy (CBT) is the most promising treatment for gambling disorder (GD) but only 21% of those with problematic gambling seek treatment. CBT over the Internet might be one way to reach a larger population. The aim of this study was to assess the effectiveness of Internet-delivered CBT with therapist guidance compared to an active control treatment.

Methods

Using a single-blinded design, 71 treatment-seeking gamblers (18-75 years) diagnosed with GD were randomized to 8 weeks of Internet-delivered CBT guided by telephone support, or 8 weeks of Internet-delivered motivational enhancement paired with motivational interviewing via telephone (IMI). The primary outcome was gambling symptoms measured at a first face-to-face assessment, baseline (treatment start), every 2 weeks, post-treatment, and 6-month follow-up. Gambling expenditures, time spent gambling, depression, anxiety, cognitive distortions, and quality of life were assessed as secondary outcomes. Analysis was performed on the full analysis sample (n = 60), with intention-to-treat sensitivity analyses (n = 69).

Results

In the CBT group, 80% stayed in treatment until the final week, compared to 67% in IMI. Post-treatment and at 6-month follow-up, no differences were found between CBT and IMI for any outcome measure. An exploratory analysis of the total sample (n = 60) showed a significant effect of time during treatment on gambling symptoms (d, [95% CI] 0.52, [-1.15, 2.02]) and all secondary outcomes except the gambling diary (depression (0.89, [-1.07-2.65]); anxiety (0.69, [-1.20-2.38])); cognitive distortions (0.84, [-0.73-2.29]); quality of life (0.60, [-0.61-1.70])). Post-treatment, there were no clinical gambling symptoms in either group. Some deterioration was seen between post-treatment and 6-month follow-up on gambling symptoms (0.42, [-1.74-2.43]), depression (0.59, [-0.82-1.86]), and anxiety (0.30, [-0.99-1.48]). Additionally, it was observed that the largest reduction in gambling symptoms was between the first assessment and baseline.

Conclusion

Both treatments offered in this study were effective at reducing gambling symptoms. It is also possible that the process of change started before treatment, which gives promise to low-intensity interventions for GD. Additional research is needed as this approach could be both cost-effective and has the potential to reach more patients in need of treatment than is currently possible.

Clinical trial registration

https://www.isrctn.com/, identifier ISRCTN38692394.

Use of tailoring features and reasons for dropout in a guided internet-based transdiagnostic individually-tailored cognitive behavioral therapy for symptoms of depression and/or anxiety in college students

Transdiagnostic individually-tailored digital interventions reduce symptoms of depression and anxiety in adults with moderate effects. However, research into these approaches for college students is scarce and contradicting. In addition, the exact reasons for intervention dropout in this target group are not well known, and the use of individually-tailored intervention features, such as optional modules, has not yet been explored. The current study aimed to (1) investigate reasons for dropout from a guided internet-based transdiagnostic individually-tailored intervention for college students assessed in a randomized controlled trial (RCT) and (2) evaluate whether participants used tailoring features intended for their baseline symptoms. A sample of college students with mild to moderate depression and/or anxiety symptoms (n = 48) in the Netherlands (partially) followed a guided internet-based transdiagnostic individually-tailored intervention. We contacted those who did not complete the entire intervention (n = 29) by phone to report the reasons for intervention dropout. Further, we descriptively explored the use of tailoring features (i.e., depression versus anxiety trajectory) and optional modules of the intervention in the whole sample. We identified a range of person- and intervention-related reasons for intervention dropout, most commonly busy schedules, needs for different kinds of help, or absence of personal contact. Furthermore, only less than half of the participants used the individually-tailoring features to address the symptoms they reported as predominant. In conclusion, digital interventions clear about the content and targeted symptoms, tested in user research could prevent dropout and create reasonable expectations of the intervention. Participants would benefit from additional guidance when using tailoring features of digital interventions, as they often do not choose the tailoring features targeting their baseline symptoms.

Improving adherence to unguided Internet-based therapy for obsessive-compulsive disorder: A randomized controlled trial

BACKGROUND

Adherence to internet-based cognitive-behavioral therapy (iCBT) is often low, possibly reducing its potential. The current study set out to test whether adherence and effects of unguided iCBT for obsessive-compulsive disorder (OCD) could be improved by varying the degree of autonomy in which modules are completed (free choice vs. fixed order).

METHODS

We randomized 151 individuals with OCD to either an unguided iCBT with a fixed (iCBTfixed) or a free-choice (iCBTfree+) order of the modules. We assessed participants at baseline (t0), eight weeks (t1), and 16 weeks (t2). Primary outcomes were adherence (utilization time, modules completed) and change in OCD severity (Y-BOCS). Secondary outcomes included depression, self-esteem, and treatment satisfaction. We calculated intent-to-treat (ITT) and complete case (CC) analyses.

RESULTS

Analyses showed that both iCBT programs significantly reduced OCD severity. While groups did not differ on the ITT analyses, for the CC analyses, a greater improvement was found in the iCBTfixed in comparison to the iCBTfree+ group regarding OCD severity and quality of life, with medium effect sizes from t0 to t1 (ηp2 = 0.067-0.077). Time of utilization and number of modules completed did not differ between groups.

LIMITATIONS

No placebo control group, short follow-up period, self-report assessment.

CONCLUSIONS

iCBT is effective in improving OCD. Despite similar adherence in the fixed versus the free-choice module order, the study offers tentative evidence that a fixed order of content is associated with better effects. More research on the effects of adherence on outcome is necessary.

Comorbidity between major depressive disorder and physical diseases: a comprehensive review of epidemiology, mechanisms and management

Populations with common physical diseases - such as cardiovascular diseases, cancer and neurodegenerative disorders - experience substantially higher rates of major depressive disorder (MDD) than the general population. On the other hand, people living with MDD have a greater risk for many physical diseases. This high level of comorbidity is associated with worse outcomes, reduced adherence to treatment, increased mortality, and greater health care utilization and costs. Comorbidity can also result in a range of clinical challenges, such as a more complicated therapeutic alliance, issues pertaining to adaptive health behaviors, drug-drug interactions and adverse events induced by medications used for physical and mental disorders. Potential explanations for the high prevalence of the above comorbidity involve shared genetic and biological pathways. These latter include inflammation, the gut microbiome, mitochondrial function and energy metabolism, hypothalamic-pituitary-adrenal axis dysregulation, and brain structure and function. Furthermore, MDD and physical diseases have in common several antecedents related to social factors (e.g., socioeconomic status), lifestyle variables (e.g., physical activity, diet, sleep), and stressful live events (e.g., childhood trauma). Pharmacotherapies and psychotherapies are effective treatments for comorbid MDD, and the introduction of lifestyle interventions as well as collaborative care models and digital technologies provide promising strategies for improving management. This paper aims to provide a detailed overview of the epidemiology of the comorbidity of MDD and specific physical diseases, including prevalence and bidirectional risk; of shared biological pathways potentially implicated in the pathogenesis of MDD and common physical diseases; of socio-environmental factors that serve as both shared risk and protective factors; and of management of MDD and physical diseases, including prevention and treatment. We conclude with future directions and emerging research related to optimal care of people with comorbid MDD and physical diseases.

Harnessing Artificial Intelligence: Strategies for Mental Health Nurses in Optimizing Psychiatric Patient Care

This narrative review explores the transformative impact of Artificial Intelligence (AI) on mental health nursing, particularly in enhancing psychiatric patient care. AI technologies present new strategies for early detection, risk assessment, and improving treatment adherence in mental health. They also facilitate remote patient monitoring, bridge geographical gaps, and support clinical decision-making. The evolution of virtual mental health assistants and AI-enhanced therapeutic interventions are also discussed. These technological advancements reshape the nurse-patient interactions while ensuring personalized, efficient, and high-quality care. The review also addresses AI's ethical and responsible use in mental health nursing, emphasizing patient privacy, data security, and the balance between human interaction and AI tools. As AI applications in mental health care continue to evolve, this review encourages continued innovation while advocating for responsible implementation, thereby optimally leveraging the potential of AI in mental health nursing.

An Online Mindfulness Intervention for International Students: A Randomized Controlled Feasibility Trial

Background

Student mobility across borders poses challenges to health systems at the university and country levels. International students suffer from stress more than their local peers, however, do not seek help or underutilize existing help offers. Some barriers to help-seeking among international students are insufficient information regarding the health offers, stigma, and language, which might be overcome via culturally adapted internet and mobile-based interventions (IMI).

Method

A randomized controlled feasibility trial with a parallel design assessed the feasibility and potential efficacy of an online mindfulness intervention adapted for international university students. Participants were randomized into either an adapted online mindfulness intervention (StudiCareM-E) (IG, n = 20) or a waitlist control group (WL, n = 20). Participants were assessed at baseline (t0) and eight-week post-randomization (t1). The feasibility of StudiCareM-E was evaluated regarding intervention adherence, client satisfaction, and potential negative effects. The potential efficacy of StudiCareM-E was measured by means of the level of mindfulness, perceived stress, depression, anxiety, presenteeism, and wellbeing. Efficacy outcomes were evaluated with regression models on the intention-to-treat (ITT) sample (n = 40), adjusting for the baseline values.

Results

Participants' formative feedback suggested improvements in the content of the IMI. There were no crucial negative effects compared to WL. Assessment dropout was 35% (IG: 50%: WL: 20%), and intervention dropout was 60%. StudiCareM-E yielded significant improvements in mindfulness (β = .34), well-being (β = .37), and anxiety (β = -.42) compared to WL.

Conclusion

StudiCareM-E might be used among culturally diverse international student populations to improve their well-being. Future studies might carefully inspect the extent of the adaptation needs of their target group and design their interventions accordingly.

Perspectives on an enhanced 'Improving Access to Psychological Therapies' (IAPT) service addressing the wider determinants of mental health: a qualitative study

BACKGROUND

A new Health and Wellbeing pathway was introduced into the Improving Access to Psychological Therapies (IAPT) service in one geographical area of the UK in 2021 to address the wider determinants of mental health problems. It comprised assisted signposting to wider services and physical health promotion. This qualitative study aimed to understand stakeholders' experiences of implementing and receiving this new support and the barriers and facilitators to its delivery.

METHODS

Forty-seven interviews were conducted, with service developers (n = 6), service deliverers (n = 12), service users (n = 22) and community and clinical partners (n = 7), as part of a larger mixed-methods evaluation. Interviews were recorded, transcribed, and analysed using reflexive thematic analysis.

RESULTS

Three themes spanned all participant groups and represented key aspects of the service: (1) identifying suitability, (2) a holistic service, and (3) moving forward. The sub-themes represent the barriers and facilitators to processes working in practice, lending insight into potential service improvements. These included strengthening the quality of communication during referral and assessment, tailoring the support and delivery mode, and increasing transparency around continued care to drive sustained benefits.

LIMITATIONS

Service users may have been selected due to their positive experiences of IAPT and were not demographically representative of the population, although participants' experiences of the service did suggest variation in our sample.

CONCLUSIONS

The Health and Wellbeing pathway was perceived as having a positive impact on mental health and could reduce the burden on therapeutic services. However, service- and individual-level barriers need to be addressed to enhance statutory and community support links, manage service users' expectations, and improve accessibility for certain groups.

CBT-informed psychological interventions for adult patients with anxiety and depression symptoms: A narrative review of digital treatment options

BACKGROUND

Across a range of age, educational and clinical characteristics, adults experiencing depression and anxiety already use digital technology to manage their symptoms. Although several reviews and meta-analyses indicated feasibility and efficacy for adults with depression and anxiety, digital treatments are poorly accessed and disseminated. This review illustrates potentials and limitations of interventions that specifically leveraged unique features of digital technology and were grounded in the principles of Cognitive Behavioral Therapy (CBT).

METHODS

This systematic review followed the PRISMA guidelines. An electronic database search was conducted in October 2021. Peer-reviewed, English-language studies were included if i) they reported data from RCTs for adults aged 18+ who engaged with CBT-informed digital interventions targeting primarily depression and anxiety; ii) they used at least PHQ-9 or GAD-7 as standardized and validated assessment self-report measures for depression and anxiety.

RESULTS

Findings from 35 RCTs examining 33 interventions (25 internet-based, 6 mobile-based, a2 mobile/web) are discussed. The quality of the evidence differed widely as many small-scale RCTs reported only short-term feasibility and preliminary efficacy. Effects of CBT-informed digital interventions were substantially larger when compared to waitlist than active control conditions. Greater therapeutic benefits were observed for interventions that offered clinical assistance or were used in combination with other treatments.

CONCLUSIONS

CBT-informed digital interventions have accumulated enough scientific evidence to be positioned today as: i) a low-intensity tool for those with subclinical levels of symptoms; ii) a first step in a stepped-care approach to service delivery iii) a low-cost, easily accessible option for targeted preventive programs.

Efficacy of remotely-delivered cognitive behavioural therapy for obsessive-compulsive disorder: An updated meta-analysis of randomised controlled trials

INTRODUCTION

Despite remotely-delivered cognitive behavioural therapy (CBT) being an emerging field, the evidence of its efficacy in obsessive-compulsive disorder (OCD) is limited. We aimed to estimate the efficacy of remotely-delivered CBT for OCD, compared to face-to-face CBT and non-CBT control conditions.

METHODS

Randomised clinical trials (RCTs) identified through a systematic literature search of PubMed, Ovid/PsychINFO and Web of Science until 21/06/2021. Eligible studies included individuals with OCD evaluating at least one form of remotely-delivered CBT versus a control condition. Random-effects meta-analyses, sub-analyses, meta-regressions, heterogeneity analyses, publication bias assessment and quality assessment.

RESULTS

Twenty-two RCTs were included (n = 1796, mean age = 27.7 years, females = 59.1 %). Remotely-delivered CBT was more efficacious than non-CBT control conditions for OCD symptoms (g = 0.936 95 % CI = 0.597-1.275, p < .001), depressive symptoms (g = 0.358, 95 % CI = 0.125-0.590, p = .003) and anxiety symptoms (g = 0.468, 95 % CI = 0.135-0.800, p = .006). There were no significant differences in efficacy between remotely-delivered CBT and face-to-face CBT for OCD symptoms (g = -0.104 95 % CI = -0.391-0.184, p = .479), depressive symptoms (g = 0.138, 95 % CI = -0.044-0.320, p = .138), anxiety symptoms (g = 0.166, 95 % CI = -0.456-0.780, p = .601) or quality of life (g = 0.057, 95 % CI = -0.178-0.292, p = .489). Higher baseline severity of OCD symptoms was associated with a lower efficacy of remotely-delivered CBT compared to face-to-face CBT (β = -0.092, p = .036). The quality of the included studies was mostly identified as "low risk of bias" (45.5 %) or "some concerns" (45.5 %).

LIMITATIONS

Heterogeneity and limited evidence for some outcomes.

CONCLUSIONS

Remotely-delivered CBT appears efficacious in reducing OCD symptoms and other relevant outcomes and is therefore a viable option for increasing treatment access. Preliminary evidence suggests some individuals with severe OCD may benefit more from face-to-face than remotely-delivered CBT.

Guided Internet-Delivered Treatment for Depression: Scoping Review

BACKGROUND

Studies on guided internet-delivered treatment have demonstrated promising results for patients with depressive disorder.

OBJECTIVE

The aim of this study was to provide an overview of this research area and identify potential gaps in the research.

METHODS

In this scoping review, web-based databases were used to identify research papers published between 2010 and 2022 where guided internet-delivered treatment was administered to participants with depressive disorders, a standardized rating scale of depressive symptoms was used as the primary outcome measure, and the treatment was compared with a control condition.

RESULTS

A total of 111 studies were included, and an overview of the studies was provided. Several gaps in the research were identified regarding the design of the studies, treatments delivered, participant representation, and treatment completion.

CONCLUSIONS

This review provides a comprehensive overview of the research area, and several research gaps were identified. The use of other designs and active control conditions is recommended. Future studies should provide access to treatment manuals, and more replications should be conducted. Researchers should aim to include underrepresented populations and provide reports of comorbidities. Definitions of adequate dosage, reports of completion rates, and reasons for treatment dropout are recommended for future studies.